Infliximab use in children and adolescents with inflammatory bowel disease

Targeting inflammation: a potential approach for the treatment of depression

Major depressive disorder (MDD) or Depression is one of the serious neuropsychiatric disorders affecting over 280 million people worldwide. It is 4th important cause of disability, poor quality of life, and economic burden. Women are more affected with the depression as compared to men and severe depression can lead to suicide. Most of the antidepressants predominantly work through the modulation on the availability of monoaminergic neurotransmitter (NTs) levels in the synapse. Current antidepressants have limited efficacy and tolerability. Moreover, treatment resistant depression (TRD) is one of the main causes for failure of standard marketed antidepressants. Recently, inflammation has also emerged as a crucial factor in pathological progression of depression. Proinflammatory cytokine levels are increased in depressive patients. Antidepressant treatment may attenuate depression via modulation of pathways of inflammation, transformation in structure of brain, and synaptic plasticity. Hence, targeting inflammation may be emerged as an effective approach for the treatment of depression. The present review article will focus on the preclinical and clinical studies that targets inflammation. In addition, it also concentrates on the therapeutic approaches' that targets depression via influence on the inflammatory signaling pathways. Graphical abstract demonstrate the role of various factors in the progression and neuroinflammation, oxidative stress. It also exhibits the association of neuroinflammation, oxidative stress with depression.

Predictors of Flares in Infliximab-treated Children With Inflammatory Bowel Disease

One third of pediatric IBD patients who initially respond to infliximab (IFX) lose that response over time. This retrospective study, including 62 children treated with IFX from 2004 to 2017, aimed to identify factors associated with clinical flare. Ulcerative colitis, extreme body mass index, and lowest IFX trough levels were associated with clinical flare in the whole population. In Crohn disease patients, perianal disease was pejorative, while location proximal to ligament of Treitz was protective. Underweight patients probably correspond to the most severe cases who are more likely to relapse, with hypoalbuminemia responsible for lower systemic IFX availability. Obesity probably induces higher IFX clearance.

CT-P13: a review on a biosimilar to infliximab in the treatment of inflammatory bowel disease

Introduction: CT-P13 was developed as an infliximab biosimilar in 2013. The primary structure of CT-P13 is identical to that of original infliximab and it has highly similar higher order structure, physiochemical characteristics, and biological properties. To date, data from real-life cohorts and randomized controlled trials show comparable clinical efficacy, safety and immunogenicity of biosimilar CT-P13, and the original reference medicinal Product (RMP). Areas covered: This article reviews the comparability of CT-P13 and the RMP and focuses on the emerging clinical trial and observational cohorts data on efficacy and safety of CT-P13 in inflammatory bowel disease (IBD) patients. The development of a subcutaneous formulation of Infliximab CT-P13 is also addressed. Expert opinion: There is a plethora of evidence to show CT-P13 is non-inferior to infliximab RMP in IBD and that a switch from RMP to this biosimilar is feasible and safe. However, interchangeability and multiple switches can still not be endorsed for introduction into clinical practice.

Role of biologics and biosimilars in inflammatory bowel disease: current trends and future perspectives

Inflammatory bowel disease (IBD) is an idiopathic chronic inflammatory disease of the gastrointestinal system. The spectrum is of predominantly two types, namely, ulcerative colitis and Crohn’s disease. The incidence of IBD has been increasing steadily since 1990, and so the number of agents used in their treatment. Biologics that are derived partly or completely from living biological sources such as animals and humans have become widely available, which provide therapeutic benefits to the IBD patients. Currently, monoclonal antibodies against tumor necrosis factor-alpha (infliximab, adalimumab, certolizumab, and golimumab), integrins (vedolizumab and natalizumab), and interleukin (IL)-12 and IL-23 antagonists (ustekinumab) are approved for use in IBD. Biosimilars of infliximab and adalimumab are also available for the treatment of IBD. This review summarizes the clinical pharmacology, studies leading to their approval, overall indications and their use in IBD, usage in pregnancy and lactation, and the adverse effects of these agents. This review also summarizes the recent advances and future perspectives specific to biologics and biosimilars in IBD.

Characteristics of Pediatric Crohn's Disease in Saudi Children: A Multicenter National Study

Background and Aims. Crohn's disease (CD) is an evolving disease in KSA. Little is known about its characteristics in the Saudi population. The aims of this study were to describe the characteristics of Saudi children with CD and to determine whether the characteristics of CD in KSA are different from those seen in Western countries. Methods. In this study, children younger than eighteen years of age diagnosed with CD between January 2003 and December 2012 were included. Results. Of 330 patients identified, 186 (56.4%) were males. The median age at diagnosis was 15.8 years. A positive family history for IBD in first-degree relatives occurred in 13.6% of patients. The most common symptoms were abdominal pain (84.2%), weight loss (75.2%), and diarrhea (71.8%). The main disease location was ileocolonic (42.1%) and the main disease behavior was nonstricturing and nonpenetrating (63.6%). Perianal involvement was seen in 60 (18.2%) patients. Laboratory findings revealed anemia in 57.9% of patients, low albumin in 34.5%, and high CRP in 39.4%. Conclusions. Saudi children with CD have lower frequency of first-degree relatives with IBD, lower prevalence of early onset disease, longer diagnostic delay, higher prevalence of growth failure, and greater frequency of stricturing and penetrating disease behavior compared to Western patients.

Adherence to Infliximab Treatment in a Pediatric Inflammatory Bowel Disease Cohort

The aims of the study were to describe infliximab adherence in a pediatric inflammatory bowel disease cohort, to identify demographic and disease factors associated with adherence, and to examine differences in acute care use among adherent and nonadherent patients. Charts of patients who received infliximab at the Children's Hospital of Wisconsin (CHW) between October 2010 and October 2012 were retrospectively reviewed. A total of 151 patients met the inclusion criteria; 91.4% of the patients were adherent. Nonadherent patients had more emergency room visits and hospitalizations than adherent patients. The study is the first to show high adherence rates to infliximab in a pediatric cohort.

Anti-TNF therapy for paediatric IBD: the Scottish national experience

BACKGROUND AND AIMS

Biological agents are being increasingly used in the UK for paediatric-onset inflammatory bowel disease (PIBD) despite limited evidence and safety concerns. We evaluated effectiveness and safety in the clinical setting, highlighting drug cost pressures, using our national Scottish PIBD biological registry.

METHODS

Complete usage of the biological agents, infliximab (IFX) and adalimumab (ADA) for treatment of PIBD (in those aged <18 years) from 1 January 2000 to 30 September 2010 was collated from all treatments administered within the Scottish Paediatric Gastroenterology, Hepatology and Nutrition (PGHAN) national managed service network (all regional PGHAN centres and paediatric units within their associated district general hospitals).

RESULTS

132 children had biological therapy; 24 required both agents; 114 had Crohn's disease (CD), 16 had ulcerative colitis (UC) and 2 had IBD Unclassified (IBDU). 127 children received IFX to induce remission; 61 entered remission, 49 had partial response and 17 had no response. 72 were given maintenance IFX and 23 required dose escalation. 18 had infusion reactions and 27 had adverse events (infections/other adverse events). 29 had ADA to induce remission (28 CD and 1 UC), 24 after IFX; 10 entered remission, 12 had partial response and 7 had no response. All had maintenance; 19 required dose escalation. 12 children overall required hospitalisation due to drug toxicity. No deaths occurred with either IFX or ADA.

CONCLUSIONS

Complete accrual of the Scottish nationwide 'real-life' experience demonstrates moderate effectiveness of anti tumour necrosis factor agents in severe PIBD but duration of effect is limited; significant financial issues (drug cost-need for dose escalation and/or multiple biological usage) and safety issues exist.

Early anti-TNF treatment in pediatric Crohn's disease. Predictors of clinical outcome in a population-based cohort of newly diagnosed patients

OBJECTIVE

Pediatric Crohn's disease (CD) is often debilitating, with upper gastrointestinal (GI) involvement and complications over time. Treatment with tumor necrosis factor (TNF) blockers can induce and maintain remission. We wanted to evaluate the outcome of patients medically treated for CD to investigate whether clinical, endoscopic and biochemical factors at diagnosis are associated with the early initiation of treatment with the TNF blocker infliximab.

MATERIALS AND METHODS

Patients aged <18 years, diagnosed with CD were characterized according to the Porto criteria, with endoscopy, magnetic resonance imaging and biochemical tests before individual treatment. They were followed prospectively until a prescheduled examination within 2 years.

RESULTS

Thirty-six pediatric patients were included, 18 (50%) received infliximab. Infliximab-treated patients had shorter disease duration, more upper GI involvement (p = 0.03) and higher median C-reactive protein (CRP) (28 vs. 7.5 mg/l, p = 0.02), erythrocyte sedimentation rate (ESR) (32 vs. 18 mm/h, p = 0.01) and fecal calprotectin (1506 vs. 501 mg/kg, p = 0.01) levels. Infliximab treatment was well tolerated, and 15/18 of patients achieved clinical remission. At follow-up, 11/17 in the infliximab group and 8/13 in the non-infliximab group achieved ileocolonic mucosal healing. A majority in the infliximab group had a marked reduction of CD-specific upper GI lesions but persistence of unspecific upper GI inflammation at follow-up.

CONCLUSION

High levels of inflammatory markers and upper GI lesions were associated with initiation of infliximab treatment. A substantial proportion of patients still had unspecific lesions in the upper GI tract regardless of treatment. Future studies must clarify the prognostic role of persistent upper GI-involvement despite mucosal healing in the ileocolon.

Anti-TNF-α treatment for pelvic pain associated with endometriosis

BACKGROUND

Endometriosis is a chronic, recurring condition that can develop during the reproductive years. It is characterised by the development of endometrial tissue outside the uterine cavity. It is the most common cause of pelvic pain in women. This endometrial tissue development is dependent on oestrogen produced primarily by the ovaries and, therefore, traditional management has focused on suppression of ovarian function. Mounting evidence shows that altered immune function plays a crucial role in the genesis and development of endometriosis. In this review we considered modulation of the inflammation as an alternative approach.

OBJECTIVES

To determine the effectiveness and safety of anti-tumour necrosis factor-α (anti-TNF-α) treatment in the management of endometriosis in premenopausal women.

SEARCH METHODS

For the first publication of this review, we searched for trials in the following databases (from their inception to August 2009): Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO. In addition, we searched all reference lists of included trials and contacted experts in the field in an attempt to locate trials. We reran this search to 3 September 2012 for this update.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing anti-TNF-α drugs with placebo, no treatment, medical treatment, or surgery for pelvic pain associated with endometriosis were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data using data extraction forms. The domains assessed for risk of bias were sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting. We used risk ratios (RR) for reporting dichotomous data with 95% confidence intervals (CI), whilst we expressed continuous data as mean differences (MD). We assessed statistical heterogeneity using the I(2) statistic.

MAIN RESULTS

Only one trial involving 21 participants was included. The results showed no evidence of an effect of infliximab, one of the known anti-TNF-α drugs, on pelvic pain reduction using the Biberoglu-Behrman (BB) score (0 to 3 scale) for participants (MD -0.14, 95% CI -0.43 to 0.15), the BB score for clinicians (MD -0.14, 95% CI -0.39 to 0.11), or a visual analogue pain score (VAS, 100 mm scale) (MD -5.60, 95% CI -16.10 to 4.90), or on the use of pain killers (ibuprofen, g/day) (MD -0.10, 95% CI -0.30 to 0.10). There was no evidence of an increase in adverse events in the infliximab group compared with placebo (RR 3.73, 95% CI 0.22 to 63.66). We found no evidence of clinical benefits of infliximab for endometriotic lesions, dysmenorrhoea, dyspareunia, or pelvic tenderness. To date, there is no trial that has reported a cost-effectiveness analysis of anti-TNF-α drugs, or the odds of recurrence.

AUTHORS' CONCLUSIONS

This review was updated in 2012. The results of the original review published in 2010 remain unchanged. There is still not enough evidence to support the use of anti-TNF-α drugs in the management of women with endometriosis for the relief of pelvic pain.

Colonic Perforation in a Child with Crohn's Disease: Successful Medical Treatment Rescues from Colectomy

Background. The challenging treatment of penetrating paediatric Crohn's disease (CD) involves pharmacological and surgical approaches. Despite a proved efficacy of anti-TNF agents for treatment of complex fistula, a large number of patients cannot achieve a complete healing and relapse during the followup. Aim. We report a paediatric case with CD and colonic perforation who was successfully treated with medical therapy only, including anti-TNFα. Case Presentation. During a colonoscopy performed on a 9-year-old girl with CD, a perforation occurred in correspondence of a fistula at the colonic splenic flexure. The formation of a collection was then detected (US, enteric-CT), as well as a fistula connecting the colon to the collection. The girl was kept fasting and treated with total parenteral nutrition and antibiotic therapy. Treatment with Infliximab was also started, and after the third dose a US control showed disappearance of the collection and healing of the enteric fistula. Parenteral nutrition was progressively substituted with enteral feeding, and no surgical treatments were needed. Discussion. In pubertal children with penetrating CD, the option of an efficacious medical treatment to avoid a major surgical approach on the bowel is to be aimed for growth improvement. This approach requires a strictly monitored long-term followup.

Management of inflammatory bowel disease with infliximab and other anti-tumor necrosis factor alpha therapies

Inflammatory bowel disease (IBD), most commonly referring to Crohn's disease and ulcerative colitis, is a chronic and disabling condition with an increasing incidence in southern Europe. The etiology of IBD remains unknown, but the characteristic disproportionate inflammatory response in the gut may develop through various mechanisms at the cellular and subcellular level. Tumor necrosis factor (TNF) alpha is one crucial mediator of this abnormal immune response, and in recent years, biological therapies targeting TNFα have significantly improved the management of IBD refractory to conventional therapies. Infliximab is the best studied anti-TNFα agent, and is currently approved in the European Union for adults and children with Crohn's disease and adults with ulcerative colitis; adalimumab is indicated for Crohn's disease in adults but not children, while certolizumab was not approved in the European Union for Crohn's disease. Infliximab has confirmed efficacy in adults with Crohn's disease (including fistulizing disease) and ulcerative colitis, with benefits observed in both clinical remission and mucosal healing, it is similarly effective in children with Crohn's disease. Evidence suggests that early treatment with infliximab may improve the natural course of the disease. Adalimumab showed efficacy in adults with Crohn's disease and more limited data suggest efficacy in children with Crohn's disease. Although certolizumab pegol has also shown promising data in adults with Crohn's disease, data in children are lacking. Anti-TNFα agents are generally well tolerated, although careful monitoring for adverse events such as infections, infusion reactions, lymphomas and demyelinating diseases is warranted. A definitive causal relationship between anti-TNFα agents and various adverse events is difficult to establish, as the underlying disease and concomitant immunosuppression also predispose patients to such events. Infliximab has not been associated with an increased incidence of serious events, and adalimumab and certolizumab are also generally well tolerated in clinical trials. Both adalimumab and certolizumab pegol are associated with lower levels of drug antibodies compared with infliximab. Reactivation of latent tuberculosis is a potential risk with any anti-TNFα agent, and identification and treatment is required before initiating therapy. Although causal relationships are difficult to establish, caution is advised with anti-TNFα compounds in patients developing neurological symptoms suggestive of demyelinating disease, or in those at high risk of malignancy. Infliximab is also generally well tolerated in children; however, data are scarce for the other compounds. No increased risks associated with pregnancy have been observed for infliximab or adalimumab, but caution in pregnancy and during breast-feeding is currently advocated. In terms of future research, more long-term data are needed for both certolizumab pegol in Crohn's disease and adalimumab in ulcerative colitis. More research on the benefits of early biological treatment on disease progression is needed. In summary, the anti-TNFα inhibitors represent a momentous advance in the treatment of Crohn's disease and ulcerative colitis refractory to conventional treatments. They offer significant benefits in quality of life and mucosal healing, and may have the potential to change the evolution of the disease when given early.

Fatal group A Streptococcus purpura fulminans in a child receiving TNF-α blocker

Inhibition of tumor necrosis factor alpha (TNF-α) is effective in the treatment of many pediatric autoimmune diseases and inflammatory conditions. Commonly available biologic agents blocking TNF-α are infliximab, etanercept, and adalimumab. These agents have changed the management of rheumatic diseases in the adult population and are being used more and more in pediatric patients as safety and efficacy have been demonstrated. Infections have been the most commonly reported adverse effects of TNF-α inhibition. Granulomatous infections such as tuberculosis are well-known complications, but serious bacterial infections are also reported. We describe a fatal case of purpura fulminans caused by group A Streptococcus in an 8-year-old child with systemic juvenile idiopathic arthritis treated with etanercept. This case highlights the clinical association of severe bacterial infection and TNF-α inhibition in children. Pediatricians should educate their patients who are treated with TNF-α blockers regarding early warning symptoms and should also have a lower threshold for initiating antibiotic therapy in case of fever.

Effectiveness of infliximab in Brazilian children and adolescents with Crohn disease and ulcerative colitis according to clinical manifestations, activity indices of inflammatory bowel disease, and corticosteroid use

OBJECTIVE

The objective of the study was to evaluate the response to infliximab in children and adolescents with Crohn disease and ulcerative colitis up to week 22.

PATIENTS AND METHODS

A total of 21 patients with inflammatory bowel disease (IBD) received 5 mg/kg of infliximab at weeks 0, 2, 6, and 14. The following parameters were evaluated: clinical manifestations; activity indices of IBD, including the Pediatric Crohn Disease Activity Index for Crohn disease, the Lightiger Colitis Activity Index and the Pediatric Ulcerative Colitis Activity Index for ulcerative colitis, and the modified Harvey-Bradshaw Index for Crohn disease and ulcerative colitis; and the reduction or suspension of corticosteroid use.

RESULTS

All of the patients had improvements in clinical manifestations after the first infusion of infliximab. At week 22, 18 of 21 (85.7%) patients were categorized as being in remission, 3 of 21 (14.3%) patients were categorized as having clinical improvement, and none of the patients were categorized as having no response. There was a statistically significant difference in all of the IBD activity indices at weeks 2, 6, 14, and 22 compared with time 0. The corticosteroid use was completely discontinued in 6 of 15 patients by week 22.

CONCLUSIONS

Infliximab is effective in the treatment of Crohn disease and ulcerative colitis in children and adolescents up to week 22.

Infliximab improves inflammation and anthropometric measures in pediatric Crohn's disease

BACKGROUND AND AIM

Infliximab (IFX) is a monoclonal antibody licensed to treat medically refractory Crohn's disease (CD). Our aim was to elucidate the effects of IFX therapy on clinical, growth and serum parameters in children with CD in a single pediatric center in Sydney, Australia.

METHODS

A retrospective case series review of children treated with IFX for CD at Sydney Children's Hospital, Australia was undertaken, with a review of outcomes after starting IFX. Main outcome measures were response and remission (as measured according to improvements in Pediatric Crohn's Disease Activity Index scores and Physician Global Assessment), laboratory markers (C-reactive protein, erythrocyte sedimentation rate, hemoglobin, white cell count, lymphocytes, neutrophils, platelets, albumin) and growth (Z scores).

RESULTS

The 16 patients included had a mean age at first infusion of 13.0 years (1.25-17.5 years). Six of 12 patients (with adequate data available) were in remission at 2 weeks following the first infusion. At 1 year, 10 of 12 patients (83%) were in remission. Mean C-reactive protein and erythrocyte sedimentation rate had fallen significantly (P < 0.05) at 2 weeks (from 29 to 7 mg/L and 40 to 19 mm/h, respectively). Positive trends were observed for all other parameters, excluding lymphocytes and white cell count. At 1 year, mean Z score for body mass index improved significantly from -0.9 to -0.1 (P < 0.01).

CONCLUSIONS

Disease activity subsides in most children treated with IFX for CD. IFX therapy also improves some growth parameters. The pattern of improvement requires further elucidation, as the results in the present study suggest differing dosing frequency of infusion may achieve better efficacy.

Anti-TNF-alpha treatment for pelvic pain associated with endometriosis

BACKGROUND

Endometriosis is a chronic, recurring condition that can develop during the reproductive years. It is characterized by the development of endometrial tissue outside the uterine cavity. It is the most common cause of pelvic pain in women. This endometrial tissue development is dependent on estrogen produced primarily by the ovaries and, therefore, traditional management has focused on suppression of ovarian function. The mounting evidence shows that altered immune function plays a crucial role in the genesis and development of endometriosis. In this review we considered modulating the inflammation as an alternative approach.

OBJECTIVES

To determine the effectiveness and safety of anti-tumour necrosis factor-alpha (anti-TNF-alpha) drugs in the management of pelvic pain associated with endometriosis.

SEARCH STRATEGY

We searched for trials in the following databases (from their inception to August 2009): Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, and PsycINFO. In addition, all reference lists of included trials were searched and experts in the field were contacted in an attempt to locate trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing anti-TNF-alpha drugs with placebo, no treatment, medical treatment, or surgery for pelvic pain associated with endometriosis were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data using data extraction forms. The domains assessed for risk of bias were sequence generation, allocation concealment, blinding, incomplete outcome data, and selective outcome reporting. Risk ratios (RR) were used for reporting dichotomous data with 95% confidence intervals (CI), whilst mean differences (MD) were expressed for continuous data. Statistical heterogeneity was assessed using the I(2) statistic.

MAIN RESULTS

Only one trial involving 21 participants was included. Results showed no evidence of an effect of infliximab, one of the known anti-TNF-alpha drugs, on pain reduction using the Biberoglu-Behrman (BB) score for patients (MD -0.15, 95% CI -0.51 to 0.21), the BB score for clinicians (MD -0.15, 95% CI -0.45 to 0.15), the visual analogue pain score (VAS) (MD 11.30, 95% CI -3.00 to 25.60) and the use of pain killers (MD -0.10, 95% CI -0.60 to 0.40). There was no evidence of an increase in adverse events in the infliximab group compared with placebo (RR 3.73, 95% CI 0.22 to 63.66). No evidence of clinical benefits of infliximab was found for endometriotic lesions, dysmenorrhoea, dyspareunia or pelvic tenderness. No trial reported the effects of anti-TNF-alpha drugs using economic evaluations and the odds of recurrence.

AUTHORS' CONCLUSIONS

There is no enough evidence to support the use of anti-TNF-alpha drugs in the management of women with endometriosis for the relief of pelvic pain.

Ineffectiveness of infliximab therapy in severe infantile Crohn's disease

Crohn's disease is extremely rare in infancy and can be present in severe forms. Infants with Crohn's disease might require intensive immunosuppressive therapy. Infliximab is a chimeric mouse/human monoclonal IgG1 antibody against tumor necrosis factor-α, and completely neutralizes its biologic activity. Though widely used in the treatment of pediatric Crohn's disease, there are few data regarding its applicability in infancy. We therefore report herein our experiences with infliximab therapy in two infantile patients with Crohn's disease who were resistant to conventional therapies; one patient showed a partial response while there was no response in the second. We were unable to achieve satisfactory results from infliximab therapy. It remains to be determined whether inflammatory bowel disease starting in infancy represents a separate pathogenetic subgroup and whether the inflammatory bowel disease diagnosis should follow the exclusion of an immunodeficiency state. Studies in larger series are needed to further clarify the efficacy, safety and timing of infliximab therapy for infantile Crohn's disease patients.

Crohn disease and mycobacterial infection in children: an intriguing relationship

The relation between Crohn disease (CD) and mycobacterial infection is complex and intriguing. The 2 conditions share common immunopathogenic features, and the hypothesis that Mycobacterium avium subspecies paratuberculosis may cause CD is still under debate. Moreover, differential diagnosis between CD and intestinal tuberculosis (TB) may be challenging, especially in the growing proportion of children immigrating from countries with a high prevalence of TB. Thus, in Western countries, paediatricians who are involved in the diagnosis and management of children with CD are expected to face intestinal TB more frequently than in the past and should always consider the differential diagnosis between these 2 conditions. In addition, the use of biological agents in the treatment of CD, which may reactivate latent TB, requires the development of targeted diagnostic algorithms. Children with CD who are candidates for treatment with antitumour necrosis factor-alpha agents should be screened for latent or active TB and closely followed over time, also considering possible failure of antitubercular prophylaxis and the frequent uncharacteristic presentation of TB in children receiving antitumour necrosis factor-alpha agents. In the present review, the most recent literature findings on these topics are reported, focusing particularly on the paediatric age group.

Efficacy of adalimumab in moderate-to-severe pediatric Crohn's disease

OBJECTIVES

The use of tumor necrosis factor-alpha (TNF-alpha) antagonists has changed the therapeutic strategy for Crohn's disease (CD). Adalimumab (ADA), a fully human anti-TNF-alpha monoclonal antibody, is an effective therapy for patients with CD, both naive patients and those intolerant or refractory to Infliximab (IFX), a chimeric anti-TNF-alpha agent. However, the use of ADA is rarely reported in pediatric CD. We performed an open prospective evaluation of short- and long-term efficacy and safety of ADA in children with moderate-to-severe CD.

METHODS

A total of 23 pediatric CD patients (9 naive and 14 intolerant or unresponsive to IFX) received ADA subcutaneously as a loading schedule at weeks 0 and 2, and at every other week (eow) during a 48-week maintenance phase. Loading and maintenance doses were 160/80 and 80 mg eow in 13 cases, 120/80 and 80 mg eow in 2, and 80/40 and 40 mg eow in 8 cases. The primary efficacy outcomes were clinical remission and response at different scheduled visits along the maintenance phase. At baseline, 13 patients also received immunomodulators (IMs).

RESULTS

At weeks 2, 4, 12, 24, and 48, remission rates were 36.3, 60.8, 30.5, 50, and 65.2%, respectively, whereas response rates were 87, 88, 70, 86, and 91%, respectively. Four patients at week 24 and 2 at week 48 received IMs; the mean daily corticosteroid dose, disease activity index, C-reactive protein level, and erythrocyte sedimentation rate decreased significantly throughout the trial. No serious adverse events were recorded.

CONCLUSIONS

ADA can be an effective and safe biological agent for inducing and maintaining remission in children with moderate-to-severe CD, even in those with previous IFX therapy.

The incidence of inflammatory bowel disease in the pediatric population of Southwestern Ontario

PURPOSE

Despite a rising worldwide incidence of inflammatory bowel disease (IBD), few data exist on Canadian children. We reviewed the incidence of IBD in all children 17 years or younger in Southwestern Ontario.

MATERIALS AND METHODS

A chart review from 1997 to 2006 revealed 123 children with IBD. Patients were divided into 2 groups according to year of diagnosis: group 1 = 1997 to 2001 and group 2 = 2002 to 2006. Our catchment population was determined from census data.

RESULTS

Sex (group 1 = 52% females; group 2 = 45% females, P = .42) and age (group 1 = 12.4 +/- 3.6 years; group 2 = 12.9 +/- 3.5 years; P = .43) were similar between groups. Although the overall incidence of IBD decreased (group 1 = 14.3 cases/100,000; group 2 = 12.4 cases/100,000), the incidence of Crohn's disease nearly doubled (group 1 = 3.5 cases/100,000; group 2 = 6.01 cases/100,000) while the incidence of ulcerative colitis decreased substantially (group 1 = 10.6 cases/100,000; group 2 = 6.01 cases/100,000). The incidence of indeterminate colitis was 0.2 cases/100,000 for group 1 and 0.4 cases/100,000 for group 2. The rate of surgical intervention decreased over time, with 43% of patients requiring surgery in group 1 and 31% in group 2 (P = .17).

CONCLUSION

Despite a slight decrease in pediatric IBD incidence in Southwestern Ontario, the incidence of Crohn's disease has nearly doubled over the last decade. Reasons for this remain unclear, although given the relatively short time interval, environmental factors, rather than genetic changes, seem more likely.

Infliximab for pediatric ulcerative colitis: a retrospective Italian multicenter study

BACKGROUND

Infliximab (IFX), the chimeric anti TNFalpha antibody, an established treatment for Crohn's disease in adults and in children, is used less frequently in ulcerative colitis (UC).

AIM OF THE STUDY

To report the clinical course of pediatric patients with active UC receiving IFX.

PATIENTS AND METHODS

Charts of 22 patients were reviewed (13 male, 9 female): 4 with a severe UC attack refractory to systemic corticosteroids (CS); 18 with a protracted course, of which 16 CS-dependent and 2 CS-resistant. The baseline therapeutic program consisted of 3 consecutive intravenous infusions (0, 2, 6 weeks) of IFX (5 mg/kg), followed by a retreatment schedule (infusion every 8 weeks); azathioprine (AZA) was administered chronically in all. Clinical evaluation was done with the Lichtiger Colitis Activity Index (LCAI). Follow-up was performed until week 54. LCAI >/= 9 was considered treatment failure; a LCAI

RESULTS

All 22 patients began the study with a LCAI > 9: 12 had a full response and were on remission at week 54 and did not receive CS (8 on IFX re-treatment and AZA, 4 on AZA alone); 6 had a partial response; 4 were non responders. Colectomy was performed in 7 patients, beyond the period of the acute attack in all but one.

CONCLUSIONS

In children with severe ulcerative colitis IFX is a valuable treatment for inducing remission, avoiding emergency colectomy; retreatment may be offered to maintain remission.

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MESH Headings

• Adolescent
• Antibodies, Monoclonal/therapeutic use
• Azathioprine/therapeutic use
• Child
• Colitis, Ulcerative/drug therapy
• Drug Therapy, Combination
• Female
• Humans
• Immunosuppressive Agents/therapeutic use
• Infliximab
• Italy
• Male
• Remission Induction
• Retrospective Studies
• Salvage Therapy

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Grants Collapse

Affiliation(s)

S Cucchiara Division Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Rome "La Sapienza", Rome, Italy.
E Romeo
F Viola
M Cottone
M Fontana
G Lombardi
V Rutigliano
G L de'Angelis
T Federici

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Collaborators Collapse

Safety and efficacy of adalimumab in pediatric patients with Crohn disease

OBJECTIVES

Adalimumab has recently become available for adult patients with Crohn disease (CD) as a viable alternative tumor necrosis factor-alpha inhibitor to infliximab. To our knowledge, there have been no studies reviewing the use of adalimumab in pediatric patients with CD. Our aim was to examine the safety and efficacy of adalimumab therapy in pediatric patients with CD.

PATIENTS AND METHODS

We performed a retrospective chart review of 15 pediatric patients with CD who received adalimumab at a single institution between January 2003 and March 2007. All of the patients had a history of an attenuated response or anaphylaxis to infliximab. Each patient's chart was reviewed for age at diagnosis, sex, extent of disease, age at start of adalimumab therapy, course of therapy, side effects noted during therapy, concurrent medications, and response to adalimumab. Clinical response to adalimumab was classified as complete, partial, or no response based on the patients' ability to be weaned from steroids, increased or decreased need for steroids, or need for surgery during the course of treatment. This study was approved by the Cleveland Clinic Institutional Review Board.

RESULTS

Fifteen pediatric patients with CD received adalimumab for a 33-month period. Of those, 14 patients had adequate follow-up, and 1 patient was lost to follow-up. The mean age at initiation of therapy was 16.6 years (median 17.9 years, range 10.3-21.8 years, SD 3.1 years). The majority of patients received an 80-mg loading dose administered subcutaneously and 40-mg doses subsequently every 2 weeks. The median duration of therapy was 6.5 months (range 1-31 months). A total of 272 injections were given. Of the 14 patients with sufficient data for follow-up, 7 (50%) had a complete response, 2 (14%) had a partial response, and 5 (36%) had no response to adalimumab. Complete response was achieved after a median of 5 injections (range 3-11). Of the 14 patients with adequate follow-up, 5 had fistulizing disease; 3 of these maintained fistula closure, 1 had temporary closure, and 1 required surgery to assist with closure. Twenty-six adverse events occurred during therapy. Eight (57%) patients had at least 1 adverse effect. The most common events were abdominal pain and nausea. No serious adverse events were reported, no serious infections occurred, and no adverse events required discontinuation of adalimumab.

CONCLUSIONS

Adalimumab was well tolerated in pediatric patients with CD. Complete or partial response was observed in 64% of patients. No serious adverse events occurred during therapy. Additional studies are needed to evaluate the efficacy and to determine optimal dosing of adalimumab in the pediatric population with CD.

Alternative strategies for the use of infliximab in pediatric inflammatory bowel disease

Infliximab is approved for the induction and 1-year maintenance of remission in pediatric Crohn's disease unresponsive to conventional therapy. Despite significant experience with the use of this agent in children and adolescents who have inflammatory bowel disease, many questions about its optimal use remain. Recent safety concerns raised debate over the common practice of using infliximab in combination with conventional immunomodulatory agents. Additionally, although regularly scheduled administration maintains remission more effectively than episodic therapy, it is not known whether all patients who start infliximab must continue it for maintenance. Some patients may be able to use infliximab for induction and another agent for maintenance. Finally, the optimal placement of infliximab in the algorithm for the medical treatment of pediatric inflammatory bowel disease remains an open question.

Current view of the immunopathogenesis in inflammatory bowel disease and its implications for therapy

Although the aetiology of inflammatory bowel disease (IBD) remains unknown, the pathogenesis is gradually being unravelled, seeming to be the result of a combination of environmental, genetic, and immunological factors in which an uncontrolled immune response within the intestinal lumen leads to inflammation in genetically predisposed individuals. Multifactorial evidence suggests that a defect of innate immune response to microbial agents is involved in IBD. This editorial outlines the immunopathogenesis of IBD and their current and future therapy. We present IBD as a result of dysregulated mucosal response in the intestinal wall facilitated by defects in epithelial barrier function and the mucosal immune system with excessive production of cytokines growth factors, adhesion molecules, and reactive oxygen metabolites, resulting in tissue injury. Established and evolving therapies are discussed in the second part of this editorial and at the end of this section we review new therapies to modulate the immune system in patients with IBD.

Infliximab dependency in pediatric Crohn's disease: long-term follow-up of an unselected cohort

BACKGROUND

Infliximab is effective for induction and maintenance of remission in Crohn's disease. It is unknown how long patients should be kept on infliximab therapy. The primary aim of this study was to assess duration of effective maintenance therapy and infliximab dependency in pediatric CD patients initially responding to infliximab therapy.

METHODS

All pediatric patients treated with infliximab by pediatric gastroenterologists in the Netherlands because of severe luminal or fistulizing CD with initial response to infliximab therapy were reviewed. Duration of therapy, clinical response and adverse events were recorded.

RESULTS

Sixty-six CD patients (37 boys) in 10 hospitals were initially responding to infliximab therapy. Mean age at the start of infliximab therapy was 14.5 years (range, 8.1-18.5 years). Mean follow-up since infliximab was started was 41.3 months (range 12-165). In total, 991 infusions were administered. Analysis demonstrates that 15.2% of patients had prolonged response, while 56.1% were infliximab dependent and 28.8% lost response. In total, 10 patients (15.2%) developed an infection during infliximab therapy and 8 (12.1%) had an immediate allergic reaction.

CONCLUSIONS

Good clinical response to maintenance infliximab therapy was seen in 70% of patients. Infliximab maintenance therapy seems very effective and safe in pediatric CD. However, more than half of the patients in this cohort is dependent on repeated infliximab infusions. The number of infliximab infusions received when patients lost response to infliximab was diverse. There was no statistical difference regarding response to infliximab therapy when started early as compared to later in the course of Crohn's disease.